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32 | A test of two separate resident pendants resulted in response times of 26 seconds and 15 seconds, respectively. A test of a call button in a restroom showed a response time of one minute and 55 seconds. These findings confirm the call system is operational.
In response to the allegation that staff failed to provide adequate care and supervision to prevent falls, the LPA reviewed the file for Resident 1 (R1), who has been identified as a fall risk. The review confirmed R1 had three falls without injury in February 2024. After each incident, the facility placed R1 on a 72-hour observation watch, consistent with its policy. Records also showed that on April 11, 2024, management met with R1's Power of Attorney (POA) to propose one-on-one caregiver services, which the POA declined. Interviews with four staff members corroborated the facility's protocol for responding to resident falls.
Concerning the allegation that the facility is not providing adequate toileting care, interviews were conducted with four staff members, all of whom denied the claim. Additionally, during a facility tour on June 16, 2025, the LPA personally observed two caregivers appropriately responding to a resident's incontinence care needs.
IV. Conclusion
Based on the observations, record reviews, and interviews conducted, the Licensing Program Analyst was unable to find a preponderance of evidence to validate the allegations. While it is possible the alleged events occurred, the investigation could not produce sufficient evidence to prove that a violation of licensing regulations took place.
Therefore, the allegations are deemed UNSUBSTANTIATED.
V. Exit Interview
An exit interview was conducted with Executive Director Sara Modugno. A copy of this report was provided to her at the conclusion of the visit. |